Medicare and Opioid Safe Treatment Act or the MOST Act
This bill establishes several requirements for the Centers for Medicare & Medicaid Services (CMS), and alters requirements under Medicare and Medicare Advantage, related to pain management and opioid use.
For example, the bill requires certified opioid treatment program services to be covered under Medicare.
Additionally, among other requirements, the CMS must review payments under Medicare for opioid and non-opioid pain management procedures, specifically with respect to ambulatory outpatient surgical procedures and hospital outpatient department services. The CMS must ensure that there are no payment incentives for using opioids instead of non-opioid alternatives and must make revisions accordingly.
The bill also requires payment under Medicare to federally qualified health centers and rural health clinics that have health care practitioners who are newly certified to provide medication-assisted treatment (e.g., buprenorphine).
[Congressional Bills 115th Congress]
[From the U.S. Government Publishing Office]
[H.R. 5776 Introduced in House (IH)]
<DOC>
115th CONGRESS
2d Session
H. R. 5776
To amend title XVIII to provide for Medicare coverage of certain
services furnished by opioid treatment programs, and for other
purposes.
_______________________________________________________________________
IN THE HOUSE OF REPRESENTATIVES
May 11, 2018
Mr. Neal (for himself, Mr. Holding, Mr. Cartwright, and Mr. Taylor)
introduced the following bill; which was referred to the Committee on
Energy and Commerce, and in addition to the Committee on Ways and
Means, for a period to be subsequently determined by the Speaker, in
each case for consideration of such provisions as fall within the
jurisdiction of the committee concerned
_______________________________________________________________________
A BILL
To amend title XVIII to provide for Medicare coverage of certain
services furnished by opioid treatment programs, and for other
purposes.
Be it enacted by the Senate and House of Representatives of the
United States of America in Congress assembled,
SECTION 1. SHORT TITLE.
This Act may be cited as the ``Medicare and Opioid Safe Treatment
Act'' or the ``MOST Act''.
SEC. 2. MEDICARE COVERAGE OF CERTAIN SERVICES FURNISHED BY OPIOID
TREATMENT PROGRAMS.
(a) Coverage.--Section 1861(s)(2) of the Social Security Act (42
U.S.C. 1395x(s)(2)) is amended--
(1) in subparagraph (FF), by striking at the end ``and'';
(2) in subparagraph (GG), by inserting at the end ``;
and''; and
(3) by adding at the end the following new subparagraph:
``(HH) opioid use disorder treatment services (as
defined in subsection (jjj)).''.
(b) Opioid Use Disorder Treatment Services and Opioid Treatment
Program Defined.--Section 1861 of the Social Security Act is amended by
adding at the end the following new subsection:
``(jjj) Opioid Use Disorder Treatment Services; Opioid Treatment
Program.--
``(1) Opioid use disorder treatment services.--The term
`opioid use disorder treatment services' means items and
services that are furnished by an opioid treatment program for
the treatment of opioid abuse disorder, including--
``(A) opioid agonist treatment medications
(including oral versions) that are approved by the Food
and Drug Administration under section 505 of the
Federal Food, Drug and Cosmetic Act for use in the
treatment of opioid use disorder;
``(B) dispensing and administration of such
medications, if applicable;
``(C) substance abuse counseling by a professional
to the extent authorized under State law to furnish
such services;
``(D) behavioral individual and group therapy with
physicians or psychologists (or other mental health
professionals to the extent authorized under State
law);
``(E) toxicology testing; and
``(F) other items and services that the Secretary
determines are appropriate.
``(2) Opioid treatment program.--The term `opioid treatment
program' means an opioid treatment program (as defined in
section 8.2 of title 42 of the Code of Federal Regulations, or
any successor regulation) that--
``(A) is enrolled under section 1866(j);
``(B) has in effect a certification by the
Substance Abuse and Mental Health Services
Administration for such a program;
``(C) is accredited by an accrediting body approved
by the Substance Abuse and Mental Health Services
Administration; and
``(D) meets such additional conditions as the
Secretary may find necessary to ensure--
``(i) the health and safety of individuals
being furnished services under such program;
and
``(ii) the effective and efficient
furnishing of such services.''.
(c) Payment.--
(1) In general.--Section 1833(a)(1) of the Social Security
Act (42 U.S.C. 1395l(a)(1)) is amended--
(A) by striking ``and (BB)'' and inserting
``(BB)''; and
(B) by inserting before the semicolon at the end
the following ``, and (CC) with respect to opioid use
disorder treatment services furnished during an episode
of care, the amount paid shall be equal to the amount
payable in accordance with section 1834(w) less any
copayment required as specified by the Secretary''.
(2) Payment determination.--Section 1834 of the Social
Security Act (42 U.S.C. 1395m) is amended by adding at the end
the following new subsection:
``(w) Opioid Use Disorder Treatment Services.--
``(1) In general.--The Secretary shall pay to an opioid
treatment program (as defined in paragraph (2) of section
1861(jjj)) an amount that is equal to 100 percent of a bundled
payment under this part for opioid use disorder treatment
services (as defined in paragraph (1) of such section) that are
furnished by such program to an individual during an episode of
care (as defined by the Secretary) beginning on or after
January 1, 2020. The Secretary shall ensure that no duplicative
payments are made under this part or part D to a physician,
practitioner, or pharmacy for items and services furnished by
an opioid treatment program.
``(2) Considerations.--The Secretary may implement this
subsection through one or more bundles based on the type of
medication provided (such as buprenorphine, methadone,
naltrexone, or a new innovative drug), the frequency of
services, the scope of services furnished, characteristics of
the individuals furnished such services, or other factors as
the Secretary determine appropriate. In developing such
bundles, the Secretary may consider payment rates paid to
opioid treatment programs for comparable services under State
plans under title XIX, under the TRICARE program under chapter
55 of title 10 of the United States Code, or by other health
care payers.
``(3) Annual updates.--The Secretary shall provide an
update each year to the bundled payment amounts under this
subsection.''.
(d) Including Opioid Treatment Programs as Medicare Providers.--
Section 1866(e) of the Social Security Act (42 U.S.C. 1395cc(e)) is
amended--
(1) in paragraph (2), by striking at the end ``and'';
(2) in paragraph (3), by striking the period at the end and
inserting ``; and''; and
(3) by adding at the end the following new paragraph:
``(3) opioid treatment programs (as defined in paragraph
(2) of section 1861(jjj)), but only with respect to the
furnishing of opioid treatment program services (as defined in
paragraph (1) of such section).''.
SEC. 3. REVIEW AND ADJUSTMENT OF PAYMENTS UNDER THE MEDICARE OUTPATIENT
PROSPECTIVE PAYMENT SYSTEM TO AVOID FINANCIAL INCENTIVES
TO USE OPIOIDS INSTEAD OF NON-OPIOID ALTERNATIVE
TREATMENTS.
(a) Outpatient Prospective Payment System.--Section 1833(t) of the
Social Security Act (42 U.S.C. 1395l(t)) is amended by adding at the
end the following new paragraph:
``(22) Review and revisions of payments for non-opioid
alternative treatments.--
``(A) In general.--With respect to payments made
under this subsection for covered OPD services (or
groups of services), including covered OPD services
assigned to a comprehensive ambulatory payment
classification, the Secretary--
``(i) shall, as soon as practicable,
conduct a review (part of which may include a
request for information) of payments for
opioids and evidence-based non-opioid
alternatives for pain management (including
drugs and devices, nerve blocks, surgical
injections, and neuromodulation) with a goal of
ensuring that there are not financial
incentives to use opioids instead of non-opioid
alternatives;
``(ii) may, as the Secretary determines
appropriate, conduct subsequent reviews of such
payments; and
``(iii) shall consider the extent to which
revisions under this subsection to such
payments (such as the creation of additional
groups of covered OPD services to classify
separately those procedures that utilize
opioids and non-opioid alternatives for pain
management) would reduce payment incentives to
use opioids instead of non-opioid alternatives
for pain management.
``(B) Priority.--In conducting the review under
clause (i) of subparagraph (A) and considering
revisions under clause (iii) of such subparagraph, the
Secretary shall focus on covered OPD services (or
groups of services) assigned to a comprehensive
ambulatory payment classification, ambulatory payment
classifications that primarily include surgical
services, and other services determined by the
Secretary which generally involve treatment for pain
management.
``(C) Revisions.--If the Secretary identifies
revisions to payments pursuant to subparagraph
(A)(iii), the Secretary shall, as determined
appropriate, begin making such revisions for services
furnished on or after January 1, 2020. Revisions under
the previous sentence shall be treated as adjustments
for purposes of application of paragraph (9)(B).
``(D) Rules of construction.--Nothing in this
paragraph shall be construed to preclude the
Secretary--
``(i) from conducting a demonstration
before making the revisions described in
subparagraph (C); or
``(ii) prior to implementation of this
paragraph, from changing payments under this
subsection for covered OPD services (or groups
of services) which include opioids or non-
opioid alternatives for pain management.''.
(b) Ambulatory Surgical Centers.--Section 1833(i) of the Social
Security Act (42 U.S.C. 1395l(i)) is amended by adding at the end the
following new paragraph:
``(8) The Secretary shall apply the provisions of paragraph
(22) of section 1833(t), including the second sentence of
subparagraph (C) of such paragraph, to payment for services
under this subsection in an appropriate manner (as determined
by the Secretary).''.
SEC. 4. EXPANDING ACCESS UNDER THE MEDICARE PROGRAM TO ADDICTION
TREATMENT IN FEDERALLY QUALIFIED HEALTH CENTERS AND RURAL
HEALTH CLINICS.
(a) Federally Qualified Health Centers.--Section 1834(o) of the
Social Security Act (42 U.S.C. 1395m(o)) is amended by adding at the
end the following new paragraph:
``(3) Additional payments for certain fqhcs with
practitioners receiving data 2000 certification.--
``(A) In general.--In the case of a Federally
qualified health center with respect to which,
beginning January 1, 2019, Federally-qualified health
center services (as defined in section 1861(aa)(3)) are
furnished by a health care practitioner who first
receives on or after such date a registration or waiver
under section 303(g) of the Controlled Substances Act
to prescribe or dispense methadone, buprenorphine, or
suboxone for the purpose of maintenance or
detoxification treatment, the Secretary shall, subject
to availability of funds under subparagraph (B), make a
payment (in accordance with such timing, method, and
procedures as specified by the Secretary) to such
Federally qualified health center in an amount
determined by the Secretary, based on an approximation
of the cost to receive training for purposes of such
registration or waiver, as applicable. For purposes of
the previous sentence, a Federally-qualified health
center shall apply for a payment described in such
sentence at such time and in such manner as specified
by the Secretary and may apply for such a payment for
each practitioner furnishing such services at such
center who is described in such sentence.
``(B) Funding.--For purposes of making payments
under this paragraph, there are appropriated, out of
amounts in the Treasury not otherwise appropriated,
$6,000,000, which shall remain available until
expended.''.
(b) Rural Health Clinic.--Section 1833 of the Social Security Act
(42 U.S.C. 1395l) is amended--
(1) by redesignating the subsection (z) relating to medical
review of spinal subluxation services as subsection (aa); and
(2) by adding at the end the following new subsection:
``(bb) Additional Payments for Certain Rural Health Clinics With
Practitioners Receiving DATA 2000 Certification.--
``(1) In general.--In the case of a rural health clinic
with respect to which, beginning January 1, 2019, rural health
clinic services (as defined in section 1861(aa)(1)) are
furnished by a health care practitioner who first receives on
or after such date a registration or waiver under section
303(g) of the Controlled Substances Act to prescribe or
dispense methadone, buprenorphine, or suboxone for the purpose
of maintenance or detoxification treatment, the Secretary
shall, subject to availability of funds under subparagraph (B),
make a payment (in accordance with such timing, method, and
procedures as specified by the Secretary) to such rural health
clinic in an amount determined by the Secretary, based on an
approximation of the cost to receive training for purposes of
such registration or waiver, as applicable. For purposes of the
previous sentence, a rural health clinic shall apply for a
payment described in such sentence at such time and in such
manner as specified by the Secretary and may apply for such a
payment for each practitioner furnishing such services at such
clinic who is described in such sentence.
``(2) Funding.--For purposes of making payments under this
subsection, there are appropriated, out of amounts in the
Treasury not otherwise appropriated, $2,000,000, which shall
remain available until expended.''.
SEC. 5. STUDYING THE AVAILABILITY OF SUPPLEMENTAL BENEFITS DESIGNED TO
TREAT OR PREVENT SUBSTANCE USE DISORDERS UNDER MEDICARE
ADVANTAGE PLANS.
(a) In General.--Not later than 2 years after the date of the
enactment of this Act, the Secretary of Health and Human Services (in
this section referred to as the ``Secretary'') shall submit to Congress
a report on the availability of supplemental health care benefits (as
described in section 1852(a)(3)(A) of the Social Security Act (42
U.S.C. 1395w-22(a)(3)(A))) designed to treat or prevent substance use
disorders under Medicare Advantage plans offered under part C of title
XVIII of such Act. Such report shall include the analysis described in
subsection (c) and any differences in the availability of such benefits
under specialized MA plans for special needs individuals (as defined in
section 1859(b)(6) of such Act (42 U.S.C. 1395w-28(b)(6))) offered to
individuals entitled to medical assistance under title XIX of such Act
and other such Medicare Advantage plans.
(b) Consultation.--The Secretary shall develop the report described
in subsection (a) in consultation with relevant stakeholders,
including--
(1) individuals entitled to benefits under part A or
enrolled under part B of title XVIII of the Social Security
Act;
(2) entities who advocate on behalf of such individuals;
(3) Medicare Advantage organizations;
(4) pharmacy benefit managers; and
(5) providers of services and suppliers (as such terms are
defined in section 1861 of such Act (42 U.S.C. 1395x)).
(c) Contents.--The report described in subsection (a) shall include
an analysis on the following:
(1) The extent to which plans described in such subsection
offer supplemental health care benefits relating to coverage
of--
(A) medication-assisted treatments for opioid use,
substance use disorder counseling, peer recovery
support services, or other forms of substance use
disorder treatments (whether furnished in an inpatient
or outpatient setting); and
(B) non-opioid alternatives for the treatment of
pain.
(2) Challenges associated with such plans offering
supplemental health care benefits relating to coverage of items
and services described in subparagraph (A) or (B) of paragraph
(1).
(3) The impact, if any, of increasing the applicable rebate
percentage determined under section 1854(b)(1)(C) of the Social
Security Act (42 U.S.C. 1395w-24(b)(1)(C)) for plans offering
such benefits relating to such coverage would have on the
availability of such benefits relating to such coverage offered
under Medicare Advantage plans.
(4) Potential ways to improve upon such coverage or to
incentivize such plans to offer additional supplemental health
care benefits relating to such coverage.
SEC. 6. CLINICAL PSYCHOLOGIST SERVICES MODELS UNDER THE CENTER FOR
MEDICARE AND MEDICAID INNOVATION; GAO STUDY AND REPORT.
(a) CMI Models.--Section 1115A(b)(2)(B) of the Social Security Act
(42 U.S.C. 1315a(b)(2)(B)) is amended by adding at the end the
following new clauses:
``(xxv) Supporting ways to familiarize
individuals with the availability of coverage
under part B of title XVIII for qualified
psychologist services (as defined in section
1861(ii)).
``(xxvi) Exploring ways to avoid
unnecessary hospitalizations or emergency
department visits for mental and behavioral
health services (such as for treating
depression) through use of a 24-hour, 7-day a
week help line that may inform individuals
about the availability of treatment options,
including the availability of qualified
psychologist services (as defined in section
1861(ii)).''.
(b) GAO Study and Report.--Not later than 18 months after the date
of the enactment of this Act, the Comptroller General of the United
States shall conduct a study, and submit to Congress a report, on
mental and behavioral health services under the Medicare program under
title XVIII of the Social Security Act, including an examination of the
following:
(1) Information about services furnished by psychiatrists,
clinical psychologists, and other professionals.
(2) Information about ways that Medicare beneficiaries
familiarize themselves about the availability of Medicare
payment for qualified psychologist services (as defined in
section 1861(ii) of the Social Security Act (42 U.S.C.
1395x(ii))) and ways that the provision of such information
could be improved.
SEC. 7. PAIN MANAGEMENT STUDY.
(a) In General.--Not later than 1 year after the date of enactment
of this Act, the Secretary of Health and Human Services (referred to in
this section as the ``Secretary'') shall conduct a study and submit to
the Committee on Ways and Means and the Committee on Energy and
Commerce of the House of Representatives and the Committee on Finance
of the Senate a report containing recommendations on whether and how
payment to providers and suppliers of services and coverage related to
the use of multi-disciplinary, evidence-based, non-opioid treatments
for acute and chronic pain management for individuals entitled to
benefits under part A or enrolled under part B of title XVIII of the
Social Security Act should be revised. The Secretary shall make such
report available on the public website of the Centers for Medicare &
Medicaid Services.
(b) Consultation.--In developing the report described in subsection
(a), the Secretary shall consult with--
(1) relevant agencies within the Department of Health and
Human Services;
(2) licensed and practicing osteopathic and allopathic
physicians, behavioral health practitioners, physician
assistants, nurse practitioners, dentists, pharmacists, and
other providers of health services;
(3) providers and suppliers of services (as such terms are
defined in section 1861 of the Social Security Act (42 U.S.C.
1395x));
(4) substance abuse and mental health professional
organizations;
(5) pain management professional organizations and advocacy
entities, including individuals who personally suffer chronic
pain;
(6) medical professional organizations and medical
specialty organizations;
(7) licensed health care providers who furnish alternative
pain management services;
(8) organizations with expertise in the development of
innovative medical technologies for pain management;
(9) beneficiary advocacy organizations; and
(10) other organizations with expertise in the assessment,
diagnosis, treatment, and management of pain, as determined
appropriate by the Secretary.
(c) Contents.--The report described in subsection (a) shall include
the following:
(1) The recommendations described in subsection (d).
(2) The impact analysis described in subsection (e).
(3) An assessment of pain management guidance published by
the Federal Government that may be relevant to coverage
determinations or other coverage requirements under title XVIII
of the Social Security Act. Such assessment shall consider
incorporating into such guidance relevant elements of the ``Va/
DoD Clinical Practice Guideline for Opioid Therapy for Chronic
Pain'' published in February 2017 by the Department of Veterans
Affairs and Department of Defense, including adoption of
elements of the Department of Defense and Veterans
Administration pain rating scale.
(4) An evaluation of the following:
(A) Barriers inhibiting individuals entitled to
benefits under part A or enrolled under part B of such
title from accessing treatments and technologies
described in subparagraphs (A) through (F) of paragraph
(6).
(B) Potential legislative and administrative
changes under such title to improve individuals' access
to items and services currently covered under such
title and used for the treatment of pain, such as
cognitive behavioral interventions, physical therapy,
occupational therapy, physical medicine, biofeedback
therapy, and chiropractic therapy, and other pain
treatments services furnished in a hospital or post-
acute care setting.
(C) Costs and benefits associated with potential
expansion of coverage under such title to include items
and services not covered under such title that may be
used for the treatment of pain, such as acupuncture,
therapeutic massage, and items and services furnished
by integrated pain management programs.
(5) An analysis on payment and coverage under title XVIII
of the Social Security Act with respect to the following:
(A) Evidence-based treatments and technologies for
chronic or acute pain, including such treatments that
are covered, not covered, or have limited coverage
under such title.
(B) Evidence-based treatments and technologies that
monitor substance use withdrawal and prevent overdoses
of opioids.
(C) Evidence-based treatments and technologies that
treat substance use disorders.
(D) Items and services furnished by practitioners
through a multi-disciplinary treatment model for pain
management, including the patient-centered medical
home.
(E) Medical devices, non-opioid based drugs, and
other therapies (including interventional and
integrative pain therapies) approved or cleared by the
Food and Drug Administration for the treatment of pain.
(F) Items and services furnished to beneficiaries
with psychiatric disorders, substance use disorders, or
who are at risk of suicide, or have comorbidities and
require consultation or management of pain with one or
more specialists in pain management, mental health, or
addiction treatment.
(d) Recommendations.--The recommendations described in this
subsection are, with respect to individuals entitled to benefits under
part A or enrolled under part B of title XVIII of the Social Security
Act, legislative and administrative recommendations on the following:
(1) Options for additional coverage of pain management
therapies without the use of opioids, including interventional
pain therapies, and options to augment opioid therapy with
other clinical and complementary, integrative health services
to minimize the risk of substance use disorder, including in a
hospital setting.
(2) Options for coverage and payment modifications of
medical devices and non-opioid based pharmacological and non-
pharmacological therapies (including interventional and
integrative pain therapies) approved or cleared by the Food and
Drug Administration for the treatment of pain as an alternative
or augment to opioid therapy.
(3) Treatment strategies for beneficiaries with psychiatric
disorders, substance use disorders, or who are at risk of
suicide, and treatment strategies to address health disparities
related to opioid use and opioid abuse treatment.
(4) Treatment strategies for beneficiaries with
comorbidities who require a consultation or comanagement of
pain with one or more specialists in pain management, mental
health, or addiction treatment, including in a hospital
setting.
(5) Coadministration of opioids and other drugs,
particularly benzodiazepines.
(6) Appropriate case management for beneficiaries who
transition between inpatient and outpatient hospital settings,
or between opioid therapy to non-opioid therapy, which may
include the use of care transition plans.
(7) Outreach activities designed to educate providers of
services and suppliers under the Medicare program and
individuals entitled to benefits under part A or under part B
of such title on alternative, non-opioid therapies to manage
and treat acute and chronic pain.
(8) Creation of a beneficiary education tool on
alternatives to opioids for chronic pain management.
(e) Impact Analysis.--The impact analysis described in this
subsection consists of an analysis of any potential effects
implementing the recommendations described in subsection (d) would
have--
(1) on expenditures under the Medicare program; and
(2) on preventing or reducing opioid addiction for
individuals receiving benefits under the Medicare program.
<all>
Introduced in House
Introduced in House
Referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Referred to the Committee on Energy and Commerce, and in addition to the Committee on Ways and Means, for a period to be subsequently determined by the Speaker, in each case for consideration of such provisions as fall within the jurisdiction of the committee concerned.
Committee Consideration and Mark-up Session Held.
Ordered to be Reported (Amended) by Voice Vote.
Referred to the Subcommittee on Health.
Reported (Amended) by the Committee on Ways and Means. H. Rept. 115-764, Part I.
Reported (Amended) by the Committee on Ways and Means. H. Rept. 115-764, Part I.
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